What are the treatment options for hiccups (synchronous diaphragmatic contractions)?

Treatment of Hiccups

For intractable hiccups, chlorpromazine 25-50 mg three to four times daily is the first-line pharmacological treatment, as it is the most widely employed and FDA-approved agent for this indication. 1

Initial Management Approach

Simple Physical Maneuvers (First-Line for Acute Hiccups)

• Stimulate the uvula or pharynx through maneuvers such as drinking cold water, swallowing granulated sugar, or inducing a gag reflex to disrupt the hiccup reflex arc 2
• Disrupt diaphragmatic rhythm by breath-holding, breathing into a paper bag, or performing Valsalva maneuvers 2
• Suboccipital release technique: Apply gentle traction and pressure to the posterior neck, stretching suboccipital muscles and fascia to decompress the vagus and phrenic nerves 3

These non-invasive measures are simple, have virtually no side effects, and should be attempted first for self-limited hiccups 3.

Pharmacological Treatment (For Persistent/Intractable Hiccups)

First-Line Pharmacotherapy

Chlorpromazine remains the primary pharmacological agent:

• Dosing: 25-50 mg orally three to four times daily 1
• If symptoms persist for 2-3 days on oral therapy, parenteral administration may be indicated 1
• This is the most widely employed agent with FDA approval specifically for intractable hiccups 1, 2

Alternative Pharmacological Options

When chlorpromazine is ineffective or contraindicated, consider:

• Metoclopramide: Another widely employed agent, particularly useful given the high prevalence of gastrointestinal causes 2, 4
• Gabapentin: Effective for hiccups, especially those with neurological origins 4
• Baclofen: Acts on the reflex arc and can be effective 4

Underlying Etiology-Based Treatment

Proton pump inhibitors (PPIs) should be initiated as first-line therapy given that gastroesophageal reflux disease is the most common cause of persistent hiccups 5:

• Start empiric PPI therapy while investigating other causes 5
• Appropriate gastroenterology consultation should be obtained 5

Invasive Interventions (For Refractory Cases)

When pharmacological therapy fails:

• Phrenic nerve blockade: Can be performed with nerve stimulator guidance, though carries risk of pneumothorax, particularly in patients with thin necks 6
• Acupuncture: Has been used successfully in severe cases 2, 4
• Hypnosis: Alternative approach for intractable cases 2

Important Caveat

Phrenic nerve blockade requires careful technique and monitoring, as pneumothorax is a recognized complication requiring tube thoracostomy 6.

Diagnostic Considerations

The hiccup reflex arc involves peripheral phrenic, vagal, and sympathetic pathways with central midbrain modulation 4:

• Central causes: Stroke, space-occupying lesions, CNS injury 4
• Peripheral causes: Tumors, myocardial ischemia, herpes infection, GERD, instrumentation 4
• Drug-induced: Anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy 4

Persistent hiccups (>48 hours) or intractable hiccups (>2 months) should prompt investigation for underlying pathology 4, 5.

Treatment Algorithm Summary

1. Acute hiccups: Physical maneuvers (pharyngeal stimulation, breath-holding, suboccipital release) 2, 3
2. Persistent hiccups: Initiate PPI therapy + chlorpromazine 25-50 mg TID-QID 1, 5
3. Refractory cases: Consider alternative pharmacotherapy (gabapentin, baclofen, metoclopramide) 4
4. Intractable cases: Invasive interventions (nerve blockade, acupuncture) with appropriate specialist consultation 2, 6